Chemotherapy for Breast Cancer

Chemotherapy involves the use of chemicals that target cancer cells, which is a standard treatment for some types of breast cancer. The goal of chemotherapy, or chemo, is to improve overall survival. In some cases, however, it may be prescribed to simply provide comfort care—not allowing the tumor to get too big, which can cause other discomforts in certain cases.

Chemotherapy has been associated with potential side effects, some of which are severe. Healthcare providers are knowledgeable of such issues and can offer advice and provide tools and medications to help minimize the side effects.

Whether your oncologist recommends chemotherapy for you depends on several factors, such as tumor type and location. Discuss your specific case and concerns with your healthcare provider.

This article will give a broad overview of chemotherapy for breast cancer: how it works, how and when it's given, types of drugs used in treatment, common infusion experiences, and potential side effects after receiving treatment.

How It Works

Chemotherapy works by interfering with the ability of rapidly growing cells (like cancer cells) to divide or multiply. These powerful drugs target the growth of cancer cells by disrupting their DNA or protein production, preventing cell division, and starving them of nutrients.

Because most of an adult's normal cells are not actively dividing or multiplying, they aren't affected by chemotherapy. However, bone marrow (where your blood cells are produced), hair follicles, and the lining of the gastrointestinal (GI) tract are all constantly growing. The side effects of chemotherapy drugs are harsher on these cells than on others in your body.

Indications

Not everyone with breast cancer needs chemotherapy. It's used in four specific instances. Your healthcare provider will be able to answer your questions and discuss all options for treatment in detail.

Early-Stage Breast Cancer

Chemotherapy may be used before and/or after surgery for early-stage cancer.

Neoadjuvant chemotherapy comes before the primary treatment. Sometimes the tumor is too large to completely remove, so chemotherapy is used to shrink tumors so they're easier to take out during surgery.

In some cases, the shrinkage may allow surgeons to perform a lumpectomy (removal of the tumor) instead of a mastectomy (removal of the entire breast). Neoadjuvant therapy can eliminate cancer cells from some lymph nodes, too, so fewer of them need to be removed. It may also kill cancer cells that have spread elsewhere, reducing the risk of recurrence.

Neoadjuvant chemo is commonly given for:

• Inflammatory breast cancer
• HER2-positive breast cancer
• Triple-negative breast cancer
• High-grade tumors
• Large tumors
• Cancers that have spread to the lymph nodes

Adjuvant chemotherapy is given after the primary treatment. It's intended to kill any cancer cells that may be left in your body after surgical removal of a tumor but can't be detected on imaging tests. If left alone, these cells could grow into new tumors. Adjuvant chemotherapy lowers your risk of recurrence.

Typically for early-stage breast cancer, this chemotherapy is reserved for those with a high risk of cancer recurrence or metastasis (spreading to other areas of the body), such as when cancer cells have spread to the lymph nodes in the armpit. Hormone therapy may be an alternative option in these cases.

Advanced Breast Cancer

Chemotherapy is the main treatment for breast cancers that have metastasized (spread) beyond the breast and nearby lymph nodes.

The main goal in advanced cases is to lengthen and improve quality of life—not to cure the disease.

High-Risk Individuals

In people who are at especially high risk of developing breast cancer, chemotherapy can reduce their risk. This is called chemoprevention. Because of the risks associated with chemotherapy drugs, this is a step that needs to be carefully considered after consulting with your healthcare provider.

Chemotherapy Drugs

Many drugs are used to fight breast cancer. The most common ones for neoadjuvant and adjuvant therapy are:

• 5-fluorouracil (5-FU)
• Anthracyclines, including Adriamycin (doxorubicin) and Ellence (epirubicin)
• Cytoxan (cyclophosphamide)
• Paraplatin (carboplatin)
• Taxanes, including Taxol (paclitaxel) and Taxotere (docetaxel)

The most common chemo drugs for advanced breast cancer include:

• Anthracyclines, including Adriamycin, Ellence, and pegylated liposomal doxorubicin
• Gemzar (gemcitabine)
• Halaven (eribulin)
• Ixempra (ixabepilone)
• Navelbine (vinorelbine)
• Platinum agents (cisplatin, carboplatin)
• Taxanes, including Taxol (paclitaxel), Taxotere (docetaxel), and Abraxane (albumin-bound paclitaxel)
• Xeloda (capecitabine)

How Chemotherapy Is Given

Many chemotherapy drugs for breast cancer are given in liquid form, as intravenous (IV, into the vein) infusions or injections (into the skin), but some are available as pills or tablets.

Some drugs may be given alone, and other drugs are combined to work together. When chemo drugs are given in combination, the treatment is called a regimen.

Some of the common regimens are:

• AC: Adriamycin and Cytoxan
• EC: Epirubicin and Cytoxan
• ACT: Adriamycin and Cytoxan followed by a Taxol or Taxotere
• ECT: Epirubicin and Cytoxan followed by a Taxol or Taxotere
• CAF: Cytoxan, Adriamycin, and 5-FU
• CEF: Cytoxan, Ellence, and 5-FU
• CMF: Cytoxan, Trexall (methotrexate), and 5-FU
• TC: Taxotere and Cytoxan
• TAC: Taxotere, Adriamycin, and Cytoxan

Several types of targeted therapies have been approved for many cancer types, including breast cancer. For example, a therapy that targets the HER2 receptor (necessary for those with HER2-positive breast cancer) is an antibody treatment called trastuzumab.

Timing

The frequency of your chemo treatments and the duration of the therapy as a whole depend on the method you are getting, your response to treatment, and other factors.

Frequency

Typically, chemo infusions are given once every three weeks. While the drugs continue to work, your body will use the extra time to recover your blood counts, hopefully back toward more normal levels.

Low-dose chemo, such as Taxol, is given weekly, as a smaller dose of drugs will require less recovery time. This will add up to more overall chemotherapy than you would receive on a standard schedule. You may also be given a white blood cell booster shot between infusion sessions.

Oral chemo can be taken daily, or as directed. Injections may be given before, during, or after a chemo infusion.

Duration

Chemotherapy for early-stage breast cancer is generally given for about three to six months, while weekly low-dose chemotherapy infusions are usually given every three weeks for four cycles (e.g., 12 weeks). The length and dosage of your treatment will depend on multiple factors.

If you're getting infusions, you'll need to budget more time away from work or other activities than just what's needed for other therapy.

Infusion Sessions

Here's a sample schedule to help you plan:

• Day before: Take pre-chemotherapy medications (if prescribed) to prevent side effects
• Day 1: Blood draw, weigh-in, vital signs, checkup, chemo infusion
• Day 2: Shots to boost blood counts if needed
• Day 3 and until next cycle: Rest and recovery

On the day of your infusion, plan for about four hours in the clinic. Your blood will be drawn and a complete blood count (CBC) will be done. All your vital signs and weight will be taken, as this will determine the amount of your dose of chemo drugs for that day.

Your oncologist will review your blood counts and, if they're all in the proper range, you will proceed to the infusion room for your chemotherapy treatment.

After Each Chemo Treatment

If necessary, your blood will be drawn after chemo. If your red blood cells or neutrophils (a type of white blood cell) are low, you may be offered shots to boost those counts. Chemotherapy can greatly affect your blood counts because blood cells divide and multiply quickly and are therefore targeted by the drugs.

Staying on top of your blood counts is essential for recovering from chemo with a healthy immune system and avoiding anemia (low hemoglobin, a type of red blood cell) and neutropenia (low white blood cells, which help to prevent infection).

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Side Effects

The powerful nature of chemo treatment is both its strength and the reason for its harsh side effects. Remember that chemo targets all rapidly growing cells, and, in addition to cancer cells, that includes cells in your blood, digestive-tract mucous tissues, fingernails, toenails, and hair follicles.

Common side effects include:

• Hair loss
• Nail changes
• Mouth sores
• Loss of appetite
• Weight changes
• Nausea and vomiting
• Diarrhea
• Increased chance of infection
• Easy bruising
• Easy bleeding
• Fatigue
• Nerve damage
• "Chemo brain" (memory and concentration problems)

Your specific chemotherapy drug or regimen may cause other side effects, as well. These effects will subside after you've finished treatment.

Between chemotherapy appointments, if you have trouble dealing with side effects, don't hesitate to call your clinic and ask for help. For example, if you're dehydrated (not drinking enough, perhaps due to nausea) after a treatment, your healthcare providers may suggest an IV infusion of fluids. Other medications may be given along with the saline to help with nausea and vomiting.

Your chemotherapy nurses are aware of many interventions to help you cope with side effects, so be sure to ask about them, even if you don't have a scheduled appointment at that time. Write down your symptoms—along with duration, severity, and how often they occur—before you call. That will help them suggest ways to make you feel better.

Possible Complications

Chemo also carries a risk of long-term complications. You may need to be monitored for these in the years to come:

• Loss of bone mass (osteopenia and osteoporosis): Chemotherapy drugs can cause early menopause, and that leads to an elevated risk of bone-thinning conditions. Bone density tests and treatment may be necessary.
• Heart damage: Some chemotherapy comes with a slight risk of weakening the heart muscle or causing other problems with the heart.
• Leukemia (cancer of the blood cells): This side effect is rare, but possible, and usually occurs years after chemo is completed.

Fertility

Because specific chemo drugs can trigger medical menopause (which can be temporary or permanent) in premenopausal women, the drugs can cause infertility.

If you have any thoughts about future pregnancies, let your oncologist know before you start treatment and ask what your options are. Depending on your age, drug regimen, and dosage, your fertility may return after treatment. However, if there's a chance that you'll become infertile, you need to know before your first chemo infusion.

Summary

There are many types of treatment for breast cancer, including chemotherapy, which may be given intravenously (infusion), by injection, or orally (pill). While indications and duration may differ depending on the prescribed regimen, all treatment has the potential to cause side effects. If you experience any discomfort or side effects discussed above, be sure to speak with your healthcare team. Oftentimes, there are ways they can help ease these issues and relieve symptoms.